Biosafety Advisory Council
Secretariat
O./ref.: WIV-ISP/41/BAC/2015_0169
Nomination form for the expert group ‘Genetically modified animals’
Version March 2015
Please return this form completed and signed, together with a copy of your CV, to the SBB by post or
email.
Address:
Scientific Institute of Public Health, Biosafety and Biotechnology Unit (SBB)
Rue Juliette Wytsmanstraat, 14 - B 1050 Brussels – BELGIUM
Email: bac@wiv-isp.be
Last name : ..............................................................................................................................................
First name ...............................................................................................................................................
Gender: ....................................................................................................................................................
Year of birth: ...........................................................................................................................................
Identification number of the National Register: ..................................................................................

Commitment (please tick and delete where appropriate)
O I want to participate / to continue participating in the Experts group ‘Genetically modified
animals’.
Please complete the form on the next pages.
O
I don't want to participate in the Experts group 'Genetically modified animals' any longer.
Please explain briefly why you no longer wish to participate in this Expert group:
……………………………………………………………………………………………………………
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Wetenschappelijk Instituut Volksgezondheid | Institut Scientifique de Santé Publique
Dienst Bioveiligheid en Biotechnologie | Service Biosécurité et Biotechnologie
Rue Juliette Wytsmanstraat 14 | B-1050 Brussels | Belgium
T + 32 2 642 52 11 | F + 32 2 642 52 92 | bac@wiv-isp.be | www.bio-council.be
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
Contact details
Title(s): O Prof.
O Dr.
O Eng.
Institution : ...........................................................................................................................................
Department : .......................................................................................................................................
Address : .............................................................................................................................................
............................................................................................................................................................
Tel. : ....................................................................................................................................................
Email : .................................................................................................................................................

Payment
please fill in the number of the personal account to which reimbursements should be transferred
IBAN account number : .......................................................................................................................
Account holder name : ........................................................................................................................
Account holder address : ....................................................................................................................

Expertise
This section allows you to specify your main area(s) of expertise for contribution to the Expert
Group. Please tick the appropriate box(es) in the table below, indicating only the specific topics in
which you have specialised expertise.
Research disciplines
 animal production
 for food/feed
 for pets
 animal husbandry
 animal health and welfare
 molecular characterisation
 DNA/RNA/Protein analysis
 profiling techniques
 epigenetics
 post-translational modification
 inheritance and genetic stability
 ecology
 population genetics
 invasiveness
 plant-animal interactions
 biogeochemical processes
 biodiversity
 agro-ecosystems
 fresh water ecosystems
 marine ecosystems
 nature conservation
 social ecology
 taxonomy
 animal biology
 morphology
 growth
 reproduction
 development
 metabolic pathways
 mammals
 fish
 birds
 insects
continues next page
Wetenschappelijk Instituut Volksgezondheid | Institut Scientifique de Santé Publique
Dienst Bioveiligheid en Biotechnologie | Service Biosécurité et Biotechnologie
Rue Juliette Wytsmanstraat 14 | B-1050 Brussels | Belgium
T + 32 2 642 52 11 | F + 32 2 642 52 92 | bac@wiv-isp.be | www.bio-council.be
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 breeding techniques
 conventional breeding
 genetic modification
 cloning
 pathogens, infections and diseases
 bacterial diseases
 fungal diseases
 viral diseases
 animal parasites
 animal symbionts
 biological control
 Field trials
 (bio)statistics
 other:
Engineered traits
 altered characteristics:
 male sterility
 conditional lethality
 enhanced nutritional quality
 more efficient or increased production
 lower emissions to the environment
 improved fertility
 improved health characteristics
 disease resistance
 enhanced tolerance towards
environmental conditions (e.g. cold)
 particular ornamental characteristics
 production of
 pharmaceutical compounds
 biomaterials/industrial goods
 tissues/organs for xenotransplantation
 GM animals for medical models
 other:
Biosafety research on GMOs
 persistence and invasiveness
 horizontal gene transfer
 vertical gene transfer
 outcrossing to wild relatives
 interaction with target species
 interaction with non-target species
 impact on human health
 impact on biotic components and processes
 environmental impact of management
techniques
 impact on biodiversity
 post-release monitoring
 risk analysis/assessment
 other
Please specify the animal(s) for which you have expertise, indicating genus and species where
possible :
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 Other relevant disciplines: …………………………………………………………………………………...
………………………………………………………………………………………………………………………...
………………………………………………………………………………………………………………………...
Wetenschappelijk Instituut Volksgezondheid | Institut Scientifique de Santé Publique
Dienst Bioveiligheid en Biotechnologie | Service Biosécurité et Biotechnologie
Rue Juliette Wytsmanstraat 14 | B-1050 Brussels | Belgium
T + 32 2 642 52 11 | F + 32 2 642 52 92 | bac@wiv-isp.be | www.bio-council.be
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I hereby confirm that the above-mentioned information is accurate.
I have no objection to the fact that my name and affiliation will be made publicly available on the
Biosafety Council website (www.bio-council.be).
Date :
Signature :
Copy of CV added:

Additional comments
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Wetenschappelijk Instituut Volksgezondheid | Institut Scientifique de Santé Publique
Dienst Bioveiligheid en Biotechnologie | Service Biosécurité et Biotechnologie
Rue Juliette Wytsmanstraat 14 | B-1050 Brussels | Belgium
T + 32 2 642 52 11 | F + 32 2 642 52 92 | bac@wiv-isp.be | www.bio-council.be
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